Case update

Two weeks after diagnosis, Michelle undergoes a left mastectomy. During the surgery, a sentinel node biopsy is taken to see if the cancer has spread to any of Michelle’s axillary lymph nodes. Two of the nodes are found to be positive. Immediately after surgery, the tissue that was removed from Michelle’s breast is tested for receptors, to see if the cancer is responsive to hormones (oestrogen and/or progesterone) and to see if there is overexpression of HER2 receptors. She is found to have an oestrogen-positive cancer, however the cancer is not overexpressing HER2 receptors nor is it progesterone responsive. The cancer is then staged as follows:

The Nottingham Prognostic Index (NPI) is calculated as 4.4. This means that Michelle has an intermediate chance of being cured. She will, therefore, require adjuvant treatment to reduce the risk of recurrence.

Michelle makes a swift recovery from the operation and is able to go home the following day to recuperate. Before her discharge, she is seen by the breast nurse specialist who fits Michelle with a soft prosthesis which slips into her bra. She can wear this as soon as she feels comfortable. The breast nurse arranges an appointment for Michelle to return for a proper prosthetic fitting as an outpatient. She is also seen by the physiotherapist who teaches her some arm exercises that she should do daily to maintain the strength and flexibility in her left shoulder and arm.

Points to consider

The postoperative period can be extremely challenging. There are many immediate and long-term issues to deal with. Directly after surgery, the focus must be on the physical health status of the patient: oxygenation of tissues; respiratory and cardiovascular function; fluid balance; infection control; pain management; body temperature, etc. These all need careful monitoring. There are many implications of surgery in the longer terms, such as adapting to the physical appearance and/or the physical function. These may be unexpected (even if the patient was informed preoperatively) and can be extremely difficult to deal with.

Points to consider

The transition from hospital to home can be quite anxious for most patients. Leaving the security of the specialised healthcare environment can feel isolating and scary. Patients need good information about: who to call if they experience any complications; what they should/should not do once they get home; what rehabilitation exercises will assist their recovery; which medications they should take and how often; when they need any sutures/clips removed and who will do this; when they need to return for a follow-up appointment, etc. Although most patients prefer tailored information, there is so much information to take in that patients should be given a written record as well.

The role of the nurse is essential in providing supportive care. As hospital stays decrease, there is an increased need for community nurses to become more knowledgeable and skilled in caring for postoperative patients.

Points to consider

The time patients spend in hospital postoperatively is very brief, therefore it is important to prioritise their needs while they are on the ward and plan discharge from the outset. Depending on patients’ needs and the surgical procedure they have undergone, close liaison with other agencies, such as the GP, community nurses, occupational therapies, physiotherapists, pharmacists, social workers, etc., is paramount to ensure patients are safely discharged and supported once at home.

Partners, family members and informal carers can find it particularly difficult and confusing once the patient is discharged home. It is a daunting prospect being a carer: not knowing what to expect, worrying that the patient may be in pain and that you are being depended upon. There is often a temptation to want to smother or wrap the patient in cotton wool. This can be frustrating for the patient who may want to regain independence as soon as they are physically able, and may feel that their rehabilitation is hampered. It can also be difficult for partners to feel physically close to the patient, even when wounds have healed. They may fear causing pain or harm to the patient. Sometimes these anxieties continue for a significant length of time and can affect relationships and feelings of intimacy in the long term.

Case update

Michelle recovers well from her surgery and returns for her postoperative follow-up appointment. The results from the sentinel node biopsy and endocrine response are explained and Michelle is referred to the oncologist to receive six courses of chemotherapy – 5- fluorouracil (5-FU), epirubicin and cyclophosphamide (FEC). Given every 3 weeks, this will take approximately 5 months. She is given a date to meet with the chemotherapy nurse practitioner to discuss the possible side effects of the drugs and what she needs to know to stay well through her treatment. The nurse highlights that, during treatment, Michelle’s immune system will be reduced making her prone to infection. Therefore, Michelle is advised not to go to the GP practice where she works as it is a likely source of infection. Michelle returns to see the oncologist to sign a consent form and have a number of blood tests taken. A date is set for her to commence treatment.

Michelle attends the outpatient clinic the day before each cycle to see the chemotherapy nurse practitioner to check she is coping with the treatment and to have her pretreatment blood tests taken. On the day of treatment, a peripheral cannula is sited and antiemetic drugs and cytotoxic drugs are infused over 45 minutes.

Points to consider

There is a lot of information for patients to take in at the beginning of cytotoxic treatment. It is important that contact telephone numbers are given and written information is provided to refer to once at home. Information is needed so the patient and carer know what to expect and how to manage any toxicities that may occur. In particular, how to reduce infection risk is essential: meticulous hand washing; thorough aseptic care of the central venous access device (CVAD); good personal and dental hygiene; avoiding contact with other individuals with coughs/colds and crowded places; maintaining nutrition; avoiding rectal examination and medication; avoiding clearing up pet faeces; and avoiding taking antipyrexial drugs such as paracetamol. They will also need guidance on their antiemetic medication.

Patients often think that the toxicities from cytotoxic treatment are inevitable and that they have to endure them. There is also a real fear for patients that if they do report problems then the treatment will be stopped. For instance, cytotoxic-induced nausea and vomiting is intrinsically associated with chemotherapy, therefore patients expect to feel sick and do not report nausea and vomiting, but a simple adjustment of antiemetics may resolve the situation.

Reporting any adverse side effects of treatment is vital so intervention can be prompt. Patients must know who to contact and they need to do this as a matter of urgency.

Having adjuvant treatment can be difficult as patients often feel they have recovered from surgery and are beginning to re-establish a routine. It can be very time-consuming with numerous visits to the hospital.

Case update

Ten days after the second cycle of treatment, Michelle’s mouth starts to feel sore and she notices a few ulcers at the bottom of her mouth. She also doesn’t feel very well generally. She checks her temperature and discovers that she has a temperature of 38.2°C. She contacts the chemotherapy unit and is admitted to the oncology ward for intravenous (IV) antibiotics.

Points to consider

Neutropenia is a potentially life-threatening side effect of cytotoxic therapy. It is vitally important that patients report signs and symptoms of infection and receive IV antibiotics within 1 hour of arriving at hospital; this is known as the ‘door to needle time’. Because the mortality rates from neutropenic sepsis are very high in cancer patients, you need to act quickly when you are admitting the patient with suspected neutropenic sepsis. A thorough assessment is needed:

In many cancer centres, intravenous broad-spectrum antibiotics for neutropenic patients are covered by patient group directions (PGD) and are given directly after blood cultures are taken. If the patient is hypotensive then intravenous fluids will be required. Careful fluid balance measurement is needed to monitor renal function and ensure hydration. The patient will need frequent observations, depending on their status and condition. Many hospitals use an early warning score (EWS) to trigger critical care interventions if the patient starts to deteriorate.

Even with IV support and antibiotics, it may take some time for a patient’s condition to improve. This is dependent on the degree and duration of neutropenia; type and number of pathogens; the site of entry; the presence of co-morbidity; and the promptness of intervention. In addition, patients may not respond to the prescribed antibiotics, which may indicate resistant pathogens, multiple pathogens (such as viral or fungal agents) or insufficient serum levels of antibiotics (especially gentamycin and vancomycin). A regular medical review of the patient’s progress should be made, to alter or adjust treatment as needed.

If the patient’s neutrophil count has not reached 2 × 10⁹/L by the time they are due the next cycle of chemotherapy, this may delay cytotoxic treatment significantly. If this happens on a number of occassions, then colony-stimulating factors such as filgrastim (G-CSF) might be used to boost the white blood cells to ensure subsequent cycles are delivered on schedule.

Points to consider

Oral mucositis can affect the patient in many ways, physically (route of infection, reduced nutritional and fluid intake, compromised communication, pain) as well as psychosocially (reduced physical closeness with loved ones, change in body image, etc.) Pretreatment assessment is important to establish a benchmark to compare potential changes with. Assessment tools provide nurses with a guide, prompting them to conduct a systematic assessment, however the assessment tool must then be used to identify specific intervention to improve the oral cavity. Regular reassessment is required to monitor severity and impact of mucositis.

Case update

Michelle spends 4 days in hospital having intravenous antibiotics and fluids. Her temperature returns to normal and her neutrophil count increases slowly. She is discharged home and completes the remaining four cycles of cytotoxic therapy without problems.

Three weeks after completing cytotoxic therapy, Michelle commences a 5-week course of radiotherapy. She has a computed tomography CT scan to plan her treatment and spends time with one of the radiographers, who explains how the treatment works and what she should expect while having treatment. She attends the radiotherapy department daily (Monday to Friday).

Points to consider

Although enhanced radiotherapy planning techniques have improved the accuracy of treatment and reduced the incidence, severity and duration of side effects, patients still commonly experience radiation skin reactions.

The acute side effects of radiotherapy may take a number of weeks before they present, and may last long after treatment has concluded. So it is important that patients are informed of the likely time span of adverse side effects, who to report them to and how to minimise the severity of the reaction. Gently washing and drying the area is essential; wearing natural fibres; avoiding sun light; and moisturising help minimise the severity of the reaction.

Case update

Two weeks after starting radiotherapy, Michelle’s skin within the radiotherapy field starts to feel taut and tender to touch and slightly red.

For the first few weeks, Michelle drives to the hospital herself, but after 3 weeks she is feeling extremely tired and is finding it very difficult to cope with family life and the travelling to and from the hospital. In particular, she finds the daily school run exhausting and is falling asleep during the day. During her last week of radiotherapy, Michelle starts to feel anxious and emotional.

Points to consider

Radiation skin reactions can be severe. A number of patients experience moist desquamation (where the skin integrity is lost significantly) and have their treatment postponed for a few days; this may reduce the efficacy of treatment.

Radiotherapy can be an arduous emotional and physical experience. The daily visits can be exhausting and can affect an individual’s ability to drive back and forth to the radiotherapy department as well as other day-to-day activities. Radiotherapy-related fatigue is difficult to manage as little can be done to reduce the unrelentless feeling of exhaustion. Ironically, exercise can help – doing 30 minutes of gentle/moderate exercise (like walking) can reduce the severity of tiredness. Planning and spacing out daily activities can help, scheduling a rest between small tasks. Accepting additional help with domestic tasks can be frustrating and psychologically challenging, with the loss of an individual’s independence, but can often be necessary to help preserve social role by preserving energy. For instance, having help with cleaning the house may allow an individual to focus energy on cooking a family meal.

Case update

Once Michelle has completed her radiotherapy, she returns to the oncologist for a post-treatment follow up. The oncologist is pleased with her progress and, although there are no signs of disease, he commences her on tamoxifen 20   mg daily for 5 years, as her cancer was oestrogen responsive. She is now considered disease free. Michelle will now be seen in the follow-up clinic every year for 5 years and will have an annual mammogram until she is 50 years old.

Points to consider

As endocrine therapy is taken orally and patients usually self-manage at home, the side effects of treatment are often under-reported and underestimated by healthcare professionals. Patients can experience severe toxicities which last for many years and they often don’t know who they should tell. Because many of the side effects affect the normal gender hormones, the patient may experience changes in their appearance and sexual functioning. For instance, it is common for male patients to experience impotence, loss of sexual desire and increased breast growth. Females may experience loss of libido, vaginal dryness and hot flushes. Patients often find these effects difficult to discuss with healthcare professionals, so it is important that healthcare professionals provide an appropriately private environment and sensitively raise the issue of such side effects, giving the patient permission to talk about any problems they may be encountering. Some patients may not wish to discuss such matters and will change the conversation, which should be respected.

Points to consider

Having completed treatment, patients are discharged home to adjust and adapt to their change of health status, which may have resulted from the cancer and/or treatment. This can be a particularly anxious time for patients, especially after the flurry of tests and treatments and the many appointments at the hospital. Patients may sit at home, not knowing what to do with themselves. They may experience major physical effects such as loss of mobility; breathlessness; fatigue; reduced nutritional intake; and gastrointestinal functioning may be disrupted as well as many more. This might mean they are not fit enough to return to previous employment and hobbies. Their social contacts may also be diminished. Many patients express feeling lost or ‘in limbo’ at this stage and it may take some time for them to adjust. They will still attend regular outpatient appointments to be monitored, however follow-up visits rarely help reduce patient anxieties (often adding to them). Telephone follow up is becoming increasingly popular. This is where a nurse specialist makes a pre-arranged phone call to the patient to enquire about their progress and to see if they require any additional support.

The next three chapters explore two very different possible paths Michelle’s story may take. Chapters 22 and 23 explore the situation where Michelle presents with secondary disease and her prognosis is poor. Chapter 23 offers an alternative ending, in which Michelle remains disease free and lives a healthy life beyond cancer. Statistically, this is the most likely outcome, reflecting the 82% of all women diagnosed with breast cancer who survive 5 years and 73% of women who survive 10 years (Rachet et al 2009).